Tag: research

Where did all the emergencies go?

April 30th, 2020 by
national cancer institute w7Pby5bDKW4 unsplash
Do you need me?

When COVID-19 hit, hospitals knew they would see a decline in elective surgeries and routine visits. After all, they canceled them! But the volume of patients visiting the emergency room has also dropped dramatically, and no one can seem to fully explain it. Sure, maybe we could expect fewer car crashes and skiing injuries. But heart attacks and strokes? If anything it seems like those numbers should be going up due to higher stress levels. Yet, the analyses in cardiac care during the pandemic show a sharp decline not only in elective cardiac procedures, but also in cardiac catheterizations for acute heart attacks, specifically, those with ST segment elevations – the most life threatening type.  

Conventional wisdom tells us that the drop in ER visits is a bad thing. Patients must be dying at home, outcomes must be worsening, and the patients that do survive will show up as train wrecks once the pandemic subsides. Those assumptions are probably true to a certain extent, but the open question is how true?   Acute conditions and complications warrant acute care.  But in the routine care of behavioral health and other chronic conditions such as diabetes and hypertension, extensive overuse of the emergency room rather than other ambulatory settings has been a prime area of concern and debate for several years.  

We know that ERs are overused in normal times. And we think they’re underused now during the pandemic, but to what extent should be analyzed and debated as we inform the necessary adaptation of our systems of care.  We expect to see an incredible amount of variation in ER utilization as the situation unfolds, by specific patient populations, urban vs rural settings, and geography-specific COVID-19 case burden. 

We are encouraged that Datavant has convened a wide variety of industry players to construct a COVID-19 Research Database, a set of de-identified data sets made freely available to enable rapid studies at scale.  The new initiative fills an important gap between quick observations that are available from small sets of real world data and clinical trials, which are robust but slow.

The ER phenomenon we’re discussing is not completely unprecedented. Researchers (and ER staff) have long observed the ‘big game effect’ – where ER visits decline as people defer them to watch their favorite team. (The Health Business Blog first reported on it in 2005: Red Sox’ success eases health care crisis.) Some, but not all, of those visits are avoided entirely without negative consequences. The COVID-19 pandemic provides an opportunity for a much longer time series. Let’s use it as a chance to study what’s going on so we can apply the lessons learned as we emerge.

What could explain sustained, lower utilization of the ER? There are a few possibilities:

  1. Many seemingly serious problems resolve on their own when people just wait. If people avoid the ER out of fear, the ‘tincture of time’ will often do the job.
  2. Less aggressive ambulatory settings are proving effective: the physician’s office, a telehealth visit, or home remedies.
  3. The momentum and logic of the ER setting makes matters seem more serious than they really are. Once someone appears there’s always something to find. (As a doctor colleague once told me, “Show me someone who’s perfectly healthy and I’ll give him a full workup to demonstrate otherwise.”)
  4. The ER is the entry point for admission to the hospital. Under fee for service, hospitals need to admit patients to make money. Depending on the proportion of available beds during these uncertain times, hospitals may be even more economically motivated than usual to fill open beds. So, once a patient arrives, they may be staying.
  5. A significant portion of ER traffic is composed of so-called ‘frequent fliers.’ Usually, they are tolerated, but in the current environment, ER staff are motivated to triage non-COVID-19 patients away from the hospital as efficiently as possible. Once this becomes evident, the ‘frequent fliers’ ground themselves.
  6. How many times have you called your doctor’s office or pharmacy and heard the recording say, “If this is a medical emergency, hang up and dial 9-1-1”? That definitely got people used to the idea that the ER is a good place for care. Clearly people are ignoring that messaging now!

So what should we do with this unexpected information?

  1. More finely tune financial incentives to discourage unneeded utilization while not discouraging needed care. We know from experience that bluntly requiring large patient financial contributions drive down both good and bad utilization.
  2. Educate people about the downside of ER visits (infection risk, treatment that’s too aggressive, likelihood of admission to hospital, provider that doesn’t know you) to balance out the current bias for ER care. People will be more receptive now and won’t immediately think that health plans are only trying to ration their care. 
  3. Consider other changes in benefit design to help the decreased utilization persist, including increased access and reimbursement for home services, telehealth, and remote management tools.
  4. Encourage physician offices and others to make better efforts to intervene quickly and prevent people from going to the ER just for convenience. This could include on-demand availability of telehealth consultations and other digital/remote management for which they would be reimbursed.

—–

By healthcare business consultant David E. Williams, president of Health Business Group and Surya Singh MD, president of Singh Healthcare Advisors.

Evidence based defensive medicine

January 15th, 2016 by

 

ID-100150831

Defensive medicine –when physicians provide or recommend unnecessary treatment or testing in order to reduce their chance of being sued– has always bothered me. It harms the patient, drives up costs, and can be self-serving by generating more income for the provider. I’m also skeptical about whether “defensive” medicine really reduces the chances of being sued.

So I was very interested in a Today’s Hospitalist article (Does defensive medicine work after all?) that reports the results of an intriguing study of hospital admissions in Florida. The study, conducted by a Harvard Medical School professor, revealed that physicians who were responsible for the most expensive hospitalizations also had the lowest likelihood of being sued (0.3% vs. 1.5%).

There are plenty of limitations –correlation isn’t causation, it’s based on hospital admissions only, maybe the doctors in the high and low spending groups aren’t comparable, etc. — and yet it does give one pause. Maybe doctors who order more tests and treat patients more intensively really do get sued less. Could it be that patients and families are less likely to sue if they feel that everything has been done for them?

The findings have serious implications, especially as we leave the era of fee for service medicine and enter the age of accountable care and capitation. Will it be possible to get physicians to be less defensive in the name of cost savings? Is it fair to do so? What role should the patient and family have? Do we in fact need some kind of liability reform?

Dr. Anupam Jena, lead author notes that malpractice is bother under and over-stated. Malpractice costs are routinely reported at only 3-5 percent of total costs, yet physicians also say malpractice is a major concern. My own suspicion is that there’s only a limited correlation between real malpractice and what physicians actually get sued for.

Image courtesy of stockimages at FreeDigitalPhotos.net

By healthcare business consultant David E. Williams, president of Health Business Group.

 

Patient experience debuts in Minnesota

August 16th, 2013 by

Minnesota residents now have a robust, objective resource to compare the patient experience of care across medical clinics. The statewide Quality Reporting and Measurement System, created by a state reform initiative in 2008, has already rolled out public reporting of clinical quality measures. The new patient experience measures are based on more than 230,000 survey results and will complement the information that’s already available.

I’m a big fan of publicly reported patient experience measures. They enable easy comparisons across different types of physicians, are based on patient reported information, and are relatively straightforward for providers to improve if they make it a priority. We’ve had statewide reporting on patient experience in Massachusetts for several years, and I’ve found the information to be useful and accurate.

Minnesota Community Measurement (MNCM) collected and analyzed the data, which is available at www.MNHealthScores.org.

“For the first time, people in Minnesota can get information about the experience that other patients, like them, have had at physician practices across the state,” said Jim Chase, MNCM president. “The survey includes important information for patients about access to care, communication, and interactions with staff. Sharing this information can help patients know what they should expect and help physician practices learn what they can do to improve the results.”

I encourage patients and family members to review the information and take it into account when choosing a practice. Health plans can and should incorporate patient experience into their network development and pay-for-performance plans.

The information on patient experience is presented at the practice site level. In general that’s ok, especially for process-sensitive measures such as ease of making appointments. However other important elements, such as communication, do vary significantly by provider even within the same practice. Although it’s more expensive to collect the data at the individual practitioner level –due to the need for larger sample sizes—the results are more valuable. Maybe with time we will see a move in that direction.

—-

By David E. Williams of the Health Business Group.

Pets in the hospital: I'm keeping an open mind

July 16th, 2013 by

I’m not an animal lover, so it’s difficult for me to relate to the idea that a pet is a real part of the family. But I’ve met enough people who genuinely feel this way, and read the statistics, so I accept it. I have also heard about therapy animals visiting sick children and adults.

Therefore it wasn’t a huge surprise to see a USA Today story about hospitals that are beginning to allow patients’ own pets to visit them in the hospital. There are some health, safety and noise concerns, but at least some places, like the pediatric hospital in Jacksonville are letting it happen. The kids, many suffering from cancer and with unpleasant prognoses, are enjoying it, at least anecdotally.

There is some research on the impact of dogs:

Unfamiliar dogs have an “energizing effect,” creating a memorable event and elevating the day’s excitement; familiar pets, on the other hand, provide a more calming and reassuring effect, said Emily Patterson, an animal welfare scientist of the American Veterinary Medical Association.

“When a trained therapy dog visits, it’s like getting a strange person to perform music. It adds excitement to your day. When your dear pet visits, it’s like a friend is visiting you. It reconnects you with your community. You feel trusted and reassured,” Patterson said.

It seems like an interesting area of study, but I also wonder to what extent such research can be done objectively.